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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 .E. Hazelton Ave. , Stockton, Calif. <br /> :FOL�01FICL USE: Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION <br /> OR PUMP PERMIT Permit No. ��' <br /> 7 � 5�6 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate)cal Health permit to construct <br /> Application is hereby made <br /> reinthe <br /> describeda uThisoappli.cati.on istmade inrict rcompliance with San dpaq+�in <br /> and/or install the work he <br /> County <br /> Ordinance No. .1862 and the Rules ,a ReBulatians of the San Joaquin 1�ealth Dis�,xict• <br /> CENSUS TRACT <br /> JOBAD RE"S L CATION <br /> F Phone <br /> 's Name <br /> -Owner Ci <br /> r� 5 <br /> Ad s s Phone <br /> i License i�;LS7�16_il <br /> Contractor's Name <br /> ...�fDEEPEN / I RECONDITION <br /> DESTRUCTION /7 <br /> TYPE OF WORK (Check) : NEW,WELL -/�l <br /> puDl INSTALLATION /` �.ME PAIR / PUMP REPLACEMENT <br /> � .J <br /> Other <br /> T,N PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TAt�IC, - SES'�R L/ ESES" SEEPAGE PIT OTHER - U <br /> SEWAGE DISPOSAL FIEL� +. <br /> TYPE OF WELL CONSTRUCTION,SPECIFICATI0 <br /> INTENDED USE Cable Tool Dia. of Well Excavation C� <br /> IndustrialDrilled D <br /> . ia. of Well Casing <br /> ;!�`Bomesticfprivate Driven Gauge of Casing j4 <br /> Domestic/public A� Depth of Groot Seal <br /> t Irrigation s,Gravel Pack p <br /> ' o�tary Type of Grout -� <br /> Other other Information' <br /> �. s _ , �• <br /> PUMP INSTALLATION: Cantracto H.P. 1 . <br /> Type of u p <br /> State Work Done <br /> .PUMP-REPLACEI�iENT: {/ - <br /> r <br /> PUMP 'tEPAIR: / / State Work Done .. <br /> --....,—Approximate Depth _ <br /> DpCTRUCTION OF WELL: We11 Diameter A . <br /> Describe Material and Procedure a . <br /> t - <br /> fthe San Joaquin <br /> ca <br /> I hereby agree to comply withal laws aodore elationsowell.. 'Liuetin.LoWithin FIFTEENDAYS <br /> and the State of California pertaining t gulating <br /> l fumih the <br /> cal <br /> al <br /> after completion of my work on a new well, Ibefo esputtin8atheJoaquino <br /> wellinuse.HeThe abover ct <br /> WELL DRILLERS REPORT of ;the well and notif thetu <br /> ledge and belief. <br /> inf ation is true to the best o g — <br /> ­--TITLE <br /> SIGNED LOT PLAN ON REVERSE SIDE) <br /> r FOR DEPARTMENT USE ONLY --7 <br /> DATE <br /> rr <br /> 4 APPLICATION ACCEPTED BY <br /> ADDITIONAL COPnENTS: l`'~' '" <br /> PHASE Ii GROUT INSPECTION PHASE III/FINAL INSPEC�'ION <br /> * ' INSPECTION BY DATE <br /> F INSPECTION.BY ! DATE ., - Q, X <br /> ING AND .FINALINSPECTION <br /> CALL FOR A•GROUT INSPECTION -PREOP. TO GROUTg . t y 5/731M <br />